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1. Major haemorrhage
2. Terminal events in MND
3. Choking
4. Spinal cord compression
5. Superior vena cava obstruction
6. Hypercalcaemia
Janet age 67
• Metastatic carcinoma of rectum
• 2 months ago metastasis in left groin
• Now deep necrotic area bleeds periodically
• Wants to stay at home
• Not aware of possible massive bleed
• What can you do medically?
• What preparations should be made?
• Would you discuss possible events with Janet and her family?
“Just in Case” drugs for a
major bleed (3 votes)
1. Morphine 10mg IM /
SC
2. Oramorph 5mg PO
3. Midazolam 10mg IM
/ SC
4. Midazolam 10mg
buccal
5. Lorazepam 1mg S/L
6. Diazepam 10mg PO
1) Haemorrhage
Risk factors
- Tumour location
GI haemorrhage most common
Lung neoplasms - haemoptysis
Head & neck cancers
Urinary and Gynae. cancers
Inguinal nodes
- Haematological malignancies / low platelets
- NSAIDs / Steroids / Anticoagulants
- Liver failure
- Radiation necrosis
1) Non - catastrophic haemorrhage
management
• Local Measures
– Direct pressure / pressure dressings
– Adrenaline 1:1000 soaked gauze
• Systemic Measures
– Tranexamic acid 1g tds
– Radiotherapy
– Interventional radiology: embolic measures
1) Catastrophic haemorrhage
management
Anticipate
– Advance care planning
– Is resuscitation / admission appropriate?
“Just in case” drugs.
Aim = rapid sedation
- Midazolam 5 – 10 mg IV / IM / SC / buccal
- Diazepam 10 - 20 mg Rectal
Betty age 65
• MND 6 months ago
• PEG tube feeding but does tolerate
small amounts of soft food
• Poor sleep, breathless on exertion
• Drooling and choking on saliva
• Now asking ‘Will I choke to death?’
• What can be done medically?
• Do MND patients choke to death?
“Just in case” drugs for
terminal event in MND (3 votes)
1. Midazolam 10 mg
SC/IM 20 mins prn
2. Lorazepam 1 mg S/L
hourly prn
3. Diazepam 10 mg PO
hourly prn
4. Morphine 10 mg SC /
IM hourly prn
5. Glycopyrronium 400
microgrammes S/C
prn
Do MND patients choke to death?Telephone interview with 121 carers present at moment of death and most of previous 24 hours.
• 88% “died peacefully”
• 0% choked to death
• 82% died respiratory failure, hypercapnic coma
• 7% sudden deaths (cardiac event?)
72% rapid deterioration and death within 24 hours
27% alert and communicating 5 mins before death
62% asleep when died
11% comatose when died
Neudart C, Oliver D et al. J Neurol (2001): 248; 612 - 616
Do MND patients choke to death?
No patients choked to death
“The natural course of the terminal
phase in MND is generally, albeit not
uniformly, a peaceful one”
2) Choking
Obstruction of pharynx, larynx or trachea
Usually due to swallowing problems
CVA
Cancers in mouth, tongue , pharynx
Plan ahead:
– resuscitation / admission / ventilation?
– sedation & terminal care?
Repeated episodes: Glycopyrronium SC / IM
Close to end of life: Midazolam SC / IM
Reg age 78
- Ca prostate 5 years, Zoladex, PSA stable 6m ago
- Urinary retention and 3 days of confusion.
- Previously independent, driving the farm tractor.
- Bloods and catheterisation
- Catheter drained 800mls bloodstained urine, dipstick protein ++, leucocytes ++, RBCs +++.
- C&E: Na 134, K 4.2, Ur 20, Cr 350
- FBC: Hb 122, WCC 18.9, Neut 15.2, Plt 142
Reg, age 78 (part 2)
Reviewed 48 hrs later
Confusion resolved
Low back pain, constant, aching, started 2/52 ago
Not able to mobilise beyond bed to chair transfers
Constipated for 10/7
Still catheterised, urine now clear
Renal function returning to normal
• What must be ruled out?
• What investigations would you request?
Key symptoms and signs in
Spinal Cord Compression (3 votes)
1. Reduced power in
limbs
2. Normal sensation in
limbs
3. Reduced anal tone
4. Urinary retention /
constipation
5. Normal perineal
sensation
6. Pain not a feature
4) Spinal Cord Compression
• Presenting features
– Known malignancy
– Back pain – progressive / unremitting
– Radicular pain in 80%
– Limb weakness – difficulty walking
– Sensory loss – saddle anaesthesia
– sensory level
– radicular loss
– Bowel & bladder – retention / incontinence
4) SCC: investigation
Urgent same day MRI scan if:
• Still movement in legs (ambulatory / paraparetic)
• Symptoms / signs changing rapidly
• RT can be same day as MRI
Investigation lower priority if paraplegic
DO NOT investigate / transfer patients
too frail or unfit for treatment
4) SCC: management
Steroids 16mg dexamethasone / day
Radiotherapy given to most patients
Surgery considered:
• Progression after radiotherapy.
• Bone collapse – stabilise spine.
• Single site.
• Fit patient (life expectancy several months)
4) SCC: supportive management
• Pressure area care
• Bowels – suppositories
• Urinary catheter
• Psychological support
• Physiotherapy (retain function, prevent
contractures)
• Discharge planning
Symptoms & signs of Superior
Vena Cava Obstruction (3 votes)
1. No headaches
2. Swelling of face /
neck / arms / chest
3. Breathlessness
4. Reduced chest
expansion
5. Prominent
collateral vessels
5) Superior Vena Cava Obstruction
97% due to cancer (lung 80%, lymphoma 15%)
Occurs in 5-10% of all lung cancer patients
Symptoms and signs:
• Swelling of the face, neck, arms/chest
• Breathlessness (50-80%)
• Collateral vessels
• Facial oedema & plethora
• Cough
• Lethargy
• Headaches
5) SVCO – management
• Refer urgently to Oncology
• Dexamethasone 16 mg daily
• Chemotherapy: Small cell Ca lung / lymphoma
• Radiotherapy: NSC Ca lung
• Consider SVC stent
Palliation:
• Opioids
• Benzodiazepines
• Corticosteroids
• Oxygen
Sarah age 51• Breast cancer 6 years
• Bone and liver metastases 2 years
• Palliative chemo finished 4 weeks ago; poorly
tolerated and disease progressing
• Daughter’s wedding in 10 days
• Deterioration over 3 days – drowsy & sleepy
• Nausea, vomiting, dehydrated
What is the differential diagnosis?
Hypercalcaemia symptoms (3 votes)
1. Nausea / vomiting
2. Itching
3. Thirst and polyuria
4. Constipation
5. Diarrhoea
6. Insomnia
Symptoms
General: fatigue, dehydration, polyuria, polydipsia
Neurological: confusion, drowsiness, coma
GI: anorexia, nausea, vomiting, constipation
6) Hypercalcaemia
Malignancies most frequently associated with hypercalcaemia
• Breast
• Myeloma
• Renal cell
• Squamous cell tumours – esp bronchus
• Lymphoma
• 10-20% of cancer patients
• Median survival 30 days
• 20% no evidence of bone metastases
6) Hypercalcaemia
6) Hypercalcaemia: causes
1) PTHrP leading to:
a) Increased osteoclast proliferation & activity
b) Increased tubular calcium reabsorption
2) Osteolysis by tumour bony deposits
6) Hypercalcaemia
Management:
– Bloods: Corrected Calcium >2.6mmol/l
• Mild – Corr. Ca. <3.0mmol/l
– Treat only if symptoms (usually symptom free)
• Severe (>3.0mmol/l)– Treatment recommended unless v. near to death
– May reduce distressing symptoms
– End stage less traumatic
6) Hypercalcaemia
Management:
• Rehydrate with N Saline 0.9%• Bisphosphonates• Rx underlying malignancy• Check Ca2+ 3/52• Improvement in 1/52
6) Hypercalcaemia
Management
• Is treatment is appropriate?
?? In the terminal stage?
• Discuss wishes
If for treatment
• IV Fluids
• IV Bisphosphonates
• ?? prophylaxis with IV bisphosphonates
Able to attend wedding and enjoy the day
A few days later drowsy and bedbound
• What are your management options?
• What do you need to consider?
Emergencies: summary
• What is the problem?
• Keep an open mind
• Can it be reversed?
• What effect will reversal have on patient's
overall condition?
• What is your medical judgment?
• What does the patient want?
• What do the carers want?
• Could treatment maintain or improve this
patient's quality of life?